Are Physician Associates a Ticking Time bomb for the NHS?

The NHS is under immense pressure, with staff shortages, long waiting times, and growing demands for services. In response, the introduction of Physician Associates (PAs) has been championed as a solution to help ease the burden on doctors and improve patient access to care. However, recent cases—including the tragic death of Pamela Marking—raise serious concerns about whether the rapid expansion of PAs in the NHS is compromising patient safety.

The Case of Pamela Marking

A recent coroner’s report into the death of Pamela Marking at East Surrey Hospital on 24 February 2024 at East Surrey Hospital has put the role of PAs under intense scrutiny. The coroner, Dr Karen Henderson, found that when Mrs. Marking first presented with a history of vomiting blood-stained fluid and abdominal pain, she was misdiagnosed by a PA in the Emergency Department as having a simple nosebleed.  Key clinical examinations were not carried out and Mrs Marking was discharged without a medical review or supervision of the PAs decision.  Mrs Marking was readmitted 2 days later and was diagnosed with an obstructed bowel which required emergency surgery. Sadly, she ultimately suffered fatal complications and passed away. Dr Henderson, flagged a number of key concerns raised were:

• Misleading job title – The term ‘Physician Associate’ led Mrs. Marking’s family to believe she was being treated by a doctor.
• Lack of public understanding – Patients and their families may not be fully aware that a PA is not medically qualified, potentially limiting their decision to pursue a second opinion.
• Lack of supervision – Despite having a ‘supervising’ consultant, the PA in this case was effectively acting independently in diagnosing and discharging a patient. The Trust took treated their PAs as equivalent to a Tier 2 resident doctor
• Training and competency concerns – The PA did not recognize critical symptoms and failed to conduct a full examination, which could have identified the underlying condition.

These findings raise serious questions about the role PAs play in the NHS, their level of training, and the adequacy of supervision.

The Growing Concern: Are PAs Doctors by Another Name?

Originally introduced in 2003, the PA role was meant to provide additional support to doctors, not replace them. However, the reality has evolved differently. PAs are increasingly being placed in roles traditionally held by doctors, sometimes seeing undifferentiated patients with minimal oversight. Unlike doctors, PAs undergo only two years of postgraduate training after completing an undergraduate degree in any subject—not necessarily medicine. Yet they are being compared to Tier 2 resident doctors without evidence to justify this equivalence.

The status of a tier 2 resident doctor is defined by British Medical Association in their publication “Doctors Titles: Explained” extracted below:

On this definition, the Trust in Mrs Marking’s case were treated a PA as an equivalent to someone who had completed 5 years of medical education and was in their second year of clinical training.  This was, in their view, justification for the lack of direct supervision.

For a qualified doctor, this clinical and theoretical training route is highly regulated and subject to frequent examination and audit. By comparison, a PA can enter a clinical environment after 2 years of education and ongoing training and oversight of their clinical awareness is unregulated.

The result? A system where patients believe they are being treated by fully qualified doctors, but in reality, they are under the care of professionals with significantly less medical training. This blurring of roles erodes public trust and as seen in Mrs. Marking’s case, can have devastating consequences and mistakes being make which could result in medical negligence.

The Risk to Patient Safety

A growing number of doctors have voiced concerns that the expansion of PAs is a threat to patient safety. In the USA, PAs are described as Physician Assistants and undergo extensive training and are integrated within a well-regulated framework.  The UK’s approach has been less structured with the blurring around titles by referring to PAs as Physician Associates, elevating the expectation from the role from a patient perspective when this was always intended to be a role which assist Doctors and alleviate pressures. There are no national guidelines setting clear boundaries for PA responsibilities, leading to significant variation across different NHS trusts.

In practice, this has resulted in PAs:

• Making diagnostic errors due to limited training.
• Lacking appropriate clinical supervision, with some functioning almost independently.
• Reducing opportunities for junior doctors to gain essential training experience, as PAs take on roles that were traditionally part of a doctor’s learning pathway.

The NHS Workforce Plan: A Dangerous Experiment?

PAs have been part of the NHS for over 20 years.  The Royal College of Physicians states:

“Physician associates (PAs) are healthcare professionals who work as part of a multidisciplinary team with supervision from a named senior doctor (GMC registered consultant or general practitioner), providing care to patients in primary, secondary and community care environments.”

There is undoubtedly a need for high quality, safe support for doctors to manage the ever-increasing demands on their time and the Conservative Government’s 2023 NHS Workforce Plan laid out ambitious targets to expand the PA workforce. While addressing staff shortages is crucial, the decision to scale up PAs instead of investing in more doctors has sparked significant controversy. PAs are often seen as a ‘cheaper’ alternative, but this cost-saving measure could backfire if increased diagnostic errors, patient harm, and litigation costs outweigh the initial financial benefits.

The decision by the General Medical Council (GMC) to regulate PAs has further fuelled concerns that the boundaries between doctors and PAs are being deliberately blurred. Universities, keen to capitalize on the demand, are rolling out PA courses with little standardisation, raising doubts about the quality of training. Shockingly, PAs can work for up to two years without passing their national exam or being on the register.

What Needs to Change?

The tragic case of Pamela Marking should serve as a wake-up call. If PAs are to remain part of the NHS workforce, urgent reforms are needed to ensure patient safety is not compromised. These should include:

• Clear differentiation between PAs and doctors – The title ‘Physician Associate’ is misleading and should be changed to reflect their true role.
• Mandatory disclosure to patients – Patients must be explicitly informed when they are being treated by a PA and have the right to request a doctor’s opinion.
• Stronger regulations and national guidelines – The government must implement strict guidelines on PA scope of practice, supervision, and accountability.
• Improved training standards – A more rigorous training program is needed to ensure PAs have the necessary clinical knowledge before being placed in frontline roles.
• A focus on investing in doctors – The NHS must prioritize recruiting and retaining doctors rather than using PAs as a short-term fix.

So, is this a Ticking Timebomb?

The NHS is facing immense pressures, and exploring new ways to deliver care is essential. However, the rapid expansion of PAs without clear safeguards is a dangerous gamble with patient safety. Cases like that of Pamela Marking highlight the potentially fatal consequences of allowing inadequately trained practitioners to operate beyond their competencies.

Without urgent action, the continued deployment of PAs under the current system could become a ticking timebomb for the NHS—one that risks undermining trust, increasing patient harm, and ultimately costing lives. The government, regulatory bodies, and NHS leaders must act now to ensure that any expansion of the PA workforce is done safely, responsibly, and with the primary focus on protecting patients rather than cutting costs.